LASOP Case Presentation Andrea D Auria, D.O. University of Southern California Department of Pathology
Clinical Presentation 62 year old male With a history of idiopathic pulmonary fibrosis 2 months status post bilateral lung transplant Diagnosed with acute rejection, on high doses of immunosuppressants Presented to hospital with bilateral chest skin lesions
Skin Lesions Erythematous nodules which enlarged Drained serous fluid after three weeks
Diagnosis Cutaneous amoebiasis Acanthamoeba Confirmed via PCR (CDC)
Special Stains CD 68 PAS AFB GMS Negative Negative Negative Negative
More History After a week of hospitalization The patient developed another lesion The patient became altered
New Skin Lesion
Second Skin Biopsy
Anti-Acanthamoeba Antibody
MRI
CSF
Acanthamoeba Ubiquitous Can cause Keratitis Granulomatous Amoebic Encephalitis (GAE) May harbor organisms Healthy individuals have serum antibodies
Life Cycle www.dpd.cdc.gov/dpdx
Pathogenicity Portals of entry Skin Paranasal sinuses / Respiratory tract Cutaneous extension may precede dissemination by weeks to months Once disseminated, almost uniformally fatal
GAE Seen in immunocompromised patients AIDS Organ transplants Chemotherapy/radiation Host cannot mount immune response Macrophages are not primed Immunosuppressed cannot form granulomas Use of multiple antibiotics can predispose
Morphology Necrotic ulceration Mixed inflammatory infiltrate Granulomas may not be present Organisms 10-60 micrometers Prominent round/ovoid nucleus Central prominent nucleolus forming halo May phagocytize red cells or neutrophils Occasional double-walled cysts Speciation cannot be achieved by morphology alone Balamuthia mandrillaris has same nuclear features
Special Stains PAS/GMS may be positive CD68 to rule out macrophages Gram stain AFB IHC stains available
Diagnosis High index of suspicion Immunocompromised patients Non-healing skin ulcers Negative stains for other microorganisms Ddx Fungus Macrophages Vasculitis Bacillary angiomatosis Confimed by PCR or IHC stains
Summary Acanthamoebae are ubiquitous Opportunistic infection in immunosuppressed patients May disseminate from skin lesions Once disseminated, almost always fatal Morphologically bland Special stains to rule out other diagnoses Can be confirmed by PCR High index of suspicion necessary for quick diagnosis
Acknowledgements Gene Kim, MD Daniel Buxton, MD Jamie Lin, MD Craig Rohan, MD Eric Broxham, MD Melanie Osby, MD Parakarma Chandrasoma, MD
References Steinberg, J.P., Galindo, R.L., Kraus, S., Khalil, G.G., Disseminated Acanthamebiasis in a Renal Transplant Recipient with Osteomyelitis and Cutaneous Lesions: Case Report and Literature Review, Clinical Infectious Disease, 2002; 35: 43-49. Walia, R., Montoya, J.G., Visvesvera, G.S., Boonton, G.C., Doyle, R.L., A case of successful treatment of cutaneous Acanthamoeba infection in a lung transplant recipient, Transplant Infectious Disease, 2006, 9: 51-54. da Rocha Azevedo, B., Tanowitz, H.B., Marciano-Cabral, F., Diagnosis of Infections Caused by Pathogenic Free-Living Amoebae, Interdisciplinary Perspectives on Infectious Diseases, 2009, Article ID 251406. Visvesvara, G.S., Moura, H., Schuster, F.L., Pathogenic and opportunistic free-living amoebae: Acanthamoeba spp., Balamuthia mandrillaris, Naegleria fowleri, and Sappinia diploidea, Federation of European Microbiological Societies, 2007, vol 50 1-26. Walochnik, J., Obwaller, A., Gruber, F., Mildner, M., Tschachler, El, Suchomel, M., Duchene, M., Auer, H., Anti-Acanthamoeba efficacy and toxicity of miltefosine in an organotypic skin equivalent, Journal of Antimicrobial Chemotherapy, 2009, vol 64, 539-545. Aichelburg, A.C., Walochnik, J., Assadian, O., Prosch, H., Steuer, A., Perneczky, G., Visvesvara, G.S., Aspock, H., Vetter, N., Successful Treatment of Disseminated Acanthamoeba sp. Infection with Miltefosine, Emerging Infectious Diseases, 2008, vol 14, no. 11.
References, cont. Duarte, A.G., Sattar, F., Granwehr, B., Aronson, J.F., Wang, Z., Lick, S., Disseminated Acanthamoebiasis after Lung Transplantation, The Journal of Heart and Lung Transplantation, 2006, 237-240. Gullett, J., Mills, J., Hadley, K., Podemski, B., Pitts, L., Gelber, R., Disseminated Granulomatous Acanthamoeba Infection Presenting as an Unusual Skin Lesion, American Journal of Medicine, 1979, vol 67, 891-896. Pritzker, A.S., Kim, B.K., Agrawal, D., Southern, P.M., Pandya, A.G., Fatal granulomatous amebic encephalitis caused by Balamuthia mandrillaris presenting as a skin lesion, Journal of the American Academy of Dermatology, 2004, vol 50, no 2, 38-41. MacLean, R.C., Hafez, N., Tripathi, S., Childress, C.G., Ghatak, N.R., Marciano-Cabral, F., Identification of Acanthamoeba sp. in paraffin-embedded CNS tissue from an HIV+ individual by PCR, Diagnostic Microbiology and Infectious Disease, 2007, vol 57, 289-294. Torno, M.S. Jr, Babapour, R., Gurevitch, A., Witt, M.D., Cutaneous acanthamebiasis in AIDS, Journal of the American Academy of Dermatology, 2000, vol 42, 351-354. Marciano-Cabral, F., Puffenbarger, R., Cabral, G.A., The Increasing Importance of Acanthamoeba Infections, Journal of Eukaryotic Microbiology, 2000, vol 47, 29-36.